| | How the IOM-Bravewell Integrative Medicine Summit Could Make a Difference: A Proposed Action Plan | |
Summary: Do you think the National Integrative Medicine Summit can make a difference? Planning for this February 25-27, 2009 gathering, sponsored by a partnership of the Institute of Medicine of the National Academies and the Bravewell Collaborative, is under way. I organize my recommended plan around areas where exploration of integrative practice could have a significant impact on the nation's medical crisis. The high notes are a health approach, outpatient services, the patient-centered medical home, respect for multiple disciplines, researching whole practices as basis for managing chronic disease, and whole cost accounting. How do you think this Summit might create possibilities which the IOM's 2005 report didn't already open?
I wrote this article originally as my regular column for Integrative Practitioner Online, which published it here. I republish it, in full, to stimulate dialogue on how you think the Institute of Medicine of the National Academies would be best served to focus its energies in this National Summit on Integrative Medicine and Health of the Public. What questions do you think should be asked, or directions pursued? What do your think of the proposals I offer? Please send me your ideas. I'll make sure the IOM staff and at least some of the planners hear from you.
For a look at the IOM's 12-person planning team please see the related Integrator article Institute of Medicine's Names Planners for Integrative Medicine Summit Named: Snyderman to Chair.
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An Action Plan for an IOM “Integrative Health Care
Summit”(first published here for at Integrative Practitioner Online - www.integrativepractitioner.com)
The
Institute of Medicine (IOM) of the National Academy of Sciences announced on March
11, 2008 that it will hold an National Summit on Integrative Medicine and Health of the Public on February 25-27,
2009.
One
notes these things. The IOM is considered by many to be the brains of US
medicine. It can be a potent influencer of government policy, research
directions and foundation giving.
Among
the most significant of IOM’s recent contributions has been leadership, if
belated, in raising awareness and stimulating action on medical errors and
medical deaths. [See To Err is Human (2000) and Crossing the Quality Chasm (2002)] But the IOM cannot be altogether proud of its track record
if it is indeed the brains of our over $2 trillion system: by the IOM’s own
accounting - and an authorship team that includes the Summit manager - between 1/3 and 1/2 of costs are for care that is wasteful and
likely harmful. Either the IOM is not usually asking the right questions,
or the brain’s messages are not being effectively translated into action by the
corporate body of US research, payment and delivery.
That’s
context. The IOM took a significant step into the complementary and alternative
healthcare world 3 years ago when it published the 337-page Report on
Complementary and Alternative Medicine in the United States. The volume considers many themes, has much good
in it, and has certainly influenced some academic behavior. But the report appears
to have had as limited an impact on the appropriate uptake of integrative
health care as the IOM’s more typical business has had in shifting the disastrous
direction of the broader medical system.
How, then, might this IOM Summit be,
instead of a regurgitation of materials already published, of optimal value to
our system in crisis? I suggest these useful
directions.
Focus on health
care, not medicine
Those
involved in “integrative practice” assert a new paradigm of clinical care which
focuses on healing and health creation in partnership with patients. A multidisciplinary
consortium of complementary healthcare educators formally asserts the value in
“recognizing the intimate relationship between health, mind, body, spirit and
environment, and emphasizing health promotion, healing, prevention and
wellness.” The paradigm is actually an “alternative” to reductive and
reactive medical models, not a “complementary” add-on. The IOM would set itself
a more productive polestar if it valued this profound shift of culture and
practice. The focus of the Summit should
be changed to “integrative health care” rather than “integrative medicine.” The
Summit is an opportunity for the IOM to actively engage a health-oriented
paradigm.
Focus on all of
the integrative disciplines, not just medical doctors
The
integrative practice field involves many disciplines. Consumer use of
mind-body, patient-centered practice is neither dominated by “medicine” (MDs)
nor is most care delivered by MDs. Over 100,000 acupuncture and Oriental medicine
practitioners, holistic nurses, chiropractors, naturopathic physicians and
others deliver most of this new-paradigm care. Consumers create their own teams
with various practitioners in central roles in different times. For the Summit to
more deeply explore these other practices would be to respect the IOM’s own
rubric from its 2005 Report:
“… the goal of integrating care should be the
provision of comprehensive care that is safe and effective, that is
collaborative and interdisciplinary, and that respects and joins effective
interventions from all sources.”
There is nothing in the rubric that says an MD
should be in the center of the integrative universe, or that organizing this
around an MD is more effective or cost effective.
Focus on the potential
value in the outpatient, patient-centered medical home arena, not just on inpatient
“complementary medicine”
Most
integrative practitioners work in outpatient environments. Yet the “integration”
dialogue has focused disproportionately on how to add “complementary therapies”
to hospital and tertiary care. Yet we know that populations with more primary,
outpatient care have better outcomes at lower cost than those in which consumers
directly access specialists and subspecialists and thus fall under the sway of
their predilections for often unnecessary surgeries and procedures. The
“patient centered medical home” movement, led by family doctors, osteopaths, internists,
pediatricians and community medicine practitioners focuses on optimizing outpatient
care. This movement purports to be interdisciplinary and values collaboration,
teams and community. This is the natural fit for incorporating integrative
practitioners and therapies. Can these
disciplines advance the patient-centered medical home movement and thus help to
right the gross imbalance toward inpatient care in our delivery structure? How might the outpatient movement gain by
linking with these natural health care allies?
Explore how integrative
practices can meet primary care needs
Despite
what we know about the importance of primary care, the United States has an
emerging, primary care shortage of huge proportions. Conventional medical
schools are not turning out enough practitioners. The IOM team would be smart
to focus on the ways the distinctly licensed complementary health care disciplines
(DC, ND, AOM, direct entry midwifery) and holistic nursing and medical
practices can help meet this societal need. We have models. Some states already
include licensed natural health practitioners as part of their primary care mix.
What special training, if any, should be required? In addition, do these integrative
disciplines model a health-focused primary care practice which may have
something to teach conventional primary care practices? Might the
bio-psycho-social model benefit from integrative inputs?
Focus research
questions on whole systems and whole practices for chronic conditions
Conventional
chronic disease management already involves multiple inputs: pharmaceuticals, counseling,
exercise, dietary advice, and etc. Integrative approaches and practitioners are
similarly multi-agent, but with a shifted intent and an additional array of tools.
The goal of such care is not to leave the whole practice of health creation for
a magic bullet, but rather to partner with the patient in an ongoing way in
health creation through the complexity and potential of patient-centered mind-body
care. The single agent placebo
controlled randomized trial is not a
gold standard in this environment; rather, it is too often an obstruction. The
research community needs its own paradigm shift to support this practice shift
to whole system, whole person chronic care. A great contribution from this
Summit toward long-term resolution of our nation’s medical crisis would be to
have this IOM effort jump into this challenging research arena with both feet.
Research on all chronic care will benefit from the integrative care workshop.
Focus on
economic outcomes using whole cost accounting
Given
the current crisis, the IOM would serve us to focus on areas where integrative
practice may provide care which also limits the direct and societal cost of
poor health. This exploration should be speculative: discover best practices
and extrapolate where cost savings might be gained through bringing health-focused
approaches and practitioners into the care continuum. The IOM team should leave
reductive analysis behind. Merely comparing medical cost to medical costs of a
given intervention dismisses the more expensive, global costs associated with
health. Included here are, for example, would be costs associated with adverse
effects of conventional treatment as well as the cost savings, to an employer,
for instance, that may come of from a patient-centered, integrative healthcare
encounter. The IOM team should take a lead from the environmental movement and
embrace whole cost accounting.
The IOM’s Summit process kicks
off with a meeting of its 12 member planning team later this week. The
effort is being managed through its Forum on the
Science of Health Care Quality Improvement and Implementation, directed by
Samantha Chao, MPH and co-chaired by former US Treasury Secretary Paul O’Neill,
MPA. This forum is charged with moving the system changes stimulated when
the IOM courageously dropped the bomb on medical errors in 2000.
This agenda for the IOM Summit -
openly exploring the potential contributions of all of the disciplines involved
in new paradigm integrative practices – could be
strategically useful as additional shock therapy. "CAM" is not, actually, "CAM." The acronym is a reductive label draped over myriad therapies and whole systems of care, many of which were modeling mind-body approaches long before medicine got on board. Maybe medicine has something
to learn from these integrative practices on how to become "health care."
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